Financial Assistance Process Policy

UPMC POLICY AND PROCEDURE MANUAL

POLICY: HS-RE0722 * INDEX TITLE: Revenue

SUBJECT: Financial Assistance Process DATE: June 12, 2020 (effective July 1, 2020)

I. POLICY

UPMC is committed to providing financial assistance to people who have health care needs and are uninsured, underinsured, ineligible for a government program, do not qualify for governmental assistance (for example Medicare or Medicaid), or who are approved for Medicaid but the specific medically necessary service is considered non-covered by Medical Assistance, or otherwise unable to pay for medically necessary care. UPMC strives to ensure that the financial capacity of people who need health care services does not prevent them from seeking or receiving care.

In order for UPMC to responsibly manage its resources and provide the appropriate level of assistance to the greatest number of persons in need, patients are expected to contribute to their cost of care based on their individual ability to pay.

Patients applying for financial assistance are also expected to cooperate with UPMC’s procedures for obtaining financial assistance or other forms of payment, those with the financial capacity to

In accordance with Federal Emergency Medical Treatment and Labor Act (EMTALA) regulations, no patients shall be screened for financial assistance or payment information prior to the rendering of a medical screening examination and to the extent necessary, services needed to treat the patient or stabilize them for transfer as applicable. The granting of financial assistance will not take into account age, gender, race, social or immigration status, sexual orientation, gender identity or religious affiliation.

Links to policies referenced within this policy can be found in Section XIV.

II. PURPOSE

This policy addresses the various types and levels of financial assistance eligibility requirements, services that are included and excluded, and the process for securing financial assistance.

III. SCOPE

This policy applies to all fully integrated United States based UPMC hospitals and physician providers. (See attachments - Facility & Provider Listings).

[Check all that apply]

☐ UPMC Children’s Hospital of Pittsburgh ☒ UPMC Pinnacle Hospitals

☒ UPMC Magee-Women’s Hospital ☐ UPMC Carlisle ☒ UPMC Altoona ☐ UPMC Memorial ☒ UPMC Bedford ☐ UPMC Lititz ☒ UPMC Chautauqua ☐ UPMC Hanover ☒ UPMC East ☒ UPMC Muncy ☒ UPMC Hamot ☒ UPMC Wellsboro ☒ UPMC Horizon ☒ UPMC Williamsport ☒ UPMC Jameson ☒ Divine Providence Campus ☒ UPMC Kane ☒ UPMC Lock Haven ☒ UPMC McKeesport ☐ UPMC Cole ☒ UPMC Mercy ☒ UPMC Somerset ☒ UPMC Northwest ☐ UPMC Western Maryland ☒ UPMC Passavant ☒ UPMC Presbyterian Shadyside ☒ Presbyterian Campus ☒ Shadyside Campus ☒ UPMC Western Psychiatric Hospital ☒ UPMC St. Margaret

IV. DEFINITIONS

For the purpose of this policy, the terms below are defined as follows:

Emergency Care or Emergency Treatment: The care or treatment for emergency medical conditions as defined by EMTALA (Emergency Medical Treatment and Active Labor Act.)

Financial Assistance: Financial assistance is the provision of healthcare services free of charge or at a discount to individuals who meet the established criteria.

Family: As defined by the U.S. Census Bureau, a group of two or more people who reside together and who are related by birth, adoption, marriage, same- sex marriage, unmarried or domestic partners.

Uninsured: The patient has no level of insurance (either private or governmental) or other potential assistance options, such as Victims of Violent Crimes, Auto Insurance, 3rd Party Liability, etc. to assist with meeting his/her payment obligations for health care services received from UPMC.

Underinsured: The patient has some level of insurance (either private or governmental) or other potential assistance options, such as Victims of Violent Crimes, Auto Insurance, 3rd Party Liability, etc. but still has out-of-pocket expenses that exceed his/her financial ability to pay for health care services at UPMC.

Income/Family Income: Income/Family Income is determined by calculating the following sources of income for all qualifying household members.

 Wages, salaries, tips  Business income  Social Security income  Pension or Retirements Income  Dividends and Interest  Rent and Royalties  Unemployment compensation  Workers’ compensation income  Alimony and child support  Legal Judgments  Cash, bank accounts and money market accounts  Matured certificates of deposit, mutual funds, bonds or other easily convertible investments that can be cashed without penalty  Support Letters  Other Income, such as income from trust funds, charitable foundations, etc.

Items that are not considered in determining income include:

 Primary Residence  Retirement Funds  Primary Vehicle

Indigence: Income falls below 250% of the Federal Poverty Guidelines.

© 2020 UPMC All Rights Reserved POLICY HS-RE0722 PAGE 6 Discounted Care: Uninsured (for UPMC Chautauqua WCA patients only, this includes those patients with insurance benefits that have become exhausted) and income falls between 251% and 400% of the Federal Poverty Guidelines.

Financial or Medical Hardship: Financial assistance that is provided as a discount to eligible patients with annualized family income in excess of 250% of the Federal Poverty Guidelines and the out of pocket expense or patient liability resulting from medical services provided by UPMC exceeds 15% of family income.

Federal Poverty Guidelines: Federal Poverty Guidelines are updated annually in the Federal Register by the United States Department of Health and Human Services under authority of subsection (2) of Section 9902 of Title 42 of the United States Code. Current Federal Poverty Guidelines can be referenced at http://aspe.hhs.gov/poverty-guidelines.

Presumptive Charity Care: The use of external publicly available data sources that provide information on a patient’s ability to pay.

V. ELIGIBILITY

A. Services Eligible under this Policy. Financial assistance is available for eligible individuals who seek or obtain emergency and other medically necessary care from UPMC Providers. This Financial Assistance Policy (FAP) covers medically necessary care as defined by the Commonwealth of Pennsylvania. The Commonwealth of

A service, item, procedure or level of care that is necessary for the proper treatment or management of an illness, injury or disability is one that:

(1) Will, or is reasonably expected to, prevent the onset of an illness, condition, injury or disability; or (2) Will, or is reasonably expected to, reduce or ameliorate the physical, mental or developmental effects of an illness, condition, injury or disability; or (3) Will assist the recipient to achieve or maintain maximum functional capacity in performing daily activities, taking into account both the functional capacity of the recipient and those functional capacities that are appropriate of recipients of the same age.

B. Services not eligible for financial assistance under this Policy regardless of whether they constitute medically necessary care include:

a. Cosmetic surgery not considered medically necessary b. All transplant and related services c. Bariatrics and all related services d. Reproduction-related procedures (such as in- vitro fertilization, vasectomies, etc.)

© 2020 UPMC All Rights Reserved POLICY HS-RE0722 PAGE 8 e. Acupuncture f. Online virtual health care visits and related telemedicine services, including virtual specialty care and second opinion services g. Services performed at any UPMC Urgent Care location h. Package Pricing - services included in a package price are bundled and subject to an inclusive rate which is not subjected to any other forms of discounting. i. Private duty nursing j. Services provided and billed by a non UPMC entity which may include lab or diagnostic testing, dental, vision and speech, occupational or physical therapies k. Patient accounts or services received by a patient who is involved in pending litigation that relates to or may result in a generation of recovery based on charges for services performed at UPMC l. Other non-covered services such as laser eye surgery, hearing aids, etc.

VI. ELIGIBILITY AND ASSISTANCE CRITERIA

A. Financial assistance will be provided in accordance with UPMC’s mission and values. Financial assistance eligibility will be considered for uninsured and underinsured patients, and those for whom it would be a financial hardship to pay in full the expected out of pocket expenses for services provided by UPMC. Financial assistance will be provided in accordance with federal, state and local laws. Applicants for financial assistance are required to

© 2020 UPMC All Rights Reserved POLICY HS-RE0722 PAGE 9 apply to public programs for available coverage, if eligible, as well as for pursuing public or private health insurance payment options for care provided by UPMC. Patients who do not cooperate in applying for programs that may pay for their healthcare services may be denied financial assistance. UPMC shall make affirmative efforts to help patients apply for public and private programs.

Typically, financial assistance is not available for patient balances consisting only of co-pays or when a person fails to comply reasonably with insurance requirements (such as obtaining authorizations and/or referrals) or for persons who opt out of available insurance coverage, regardless of whether or not the patient meets eligibility requirements.

In addition, this policy will not apply to individuals who reside outside the service area and would be required to travel in order to seek treatment from a UPMC Provider. The service area includes all counties contiguous to a UPMC facility. Non-resident international patients are excluded from financial assistance, unless the patient is treated for an emergency. UPMC, in its sole discretion, may waive these exclusions after considering all relevant facts and circumstances. Additionally, UPMC may approve financial assistance for patients utilizing presumptive charity care.

© 2020 UPMC All Rights Reserved POLICY HS-RE0722 PAGE 10 B. Patient Financial Assistance Eligibility Guidelines. Except as otherwise provided herein, services eligible under this Policy will be made available to the patient on a sliding fee scale, in accordance with financial need, as determined in reference to Federal Poverty Level guidelines published by the U.S. Department of Health and Human Services. 1

1. Indigence:

A. When a patient is uninsured and the patient’s and/or responsible party’s (ex. Parents, Spouse, etc.) income is at or below 250% of the Federal Poverty Guidelines, the patient will be approved for a 100% reduction for the care provided by the Provider. This means that the fees for services are completely waived.

B. When a patient is underinsured and the patient’s and/or responsible party’s (ex. Parents, Spouse, etc.) income is at or below 250% of the Federal Poverty Guidelines; the patient is eligible for financial assistance. The patient’s insurance will be billed, if approved the

1 Federal Poverty Guidelines for the current year are available at http://aspe.hhs.gov/poverty-guidelines. The Provider's use of federal poverty guidelines will be updated annually in conjunction with the federal poverty guideline updates published by the United States

Department of Health and Human Services.

© 2020 UPMC All Rights Reserved POLICY HS-RE0722 PAGE 11 patient may not have any patient liability after insurance, unless it is a co-payment. If the underinsured patient’s income is greater than 250% of the Federal Poverty Guidelines, the patient may be eligible for financial assistance in the form of financial or medical hardship.

2. Discounted Care: Assistance may be in the form of a discounted or reduced patient obligation depending on the patient’s and/or responsible party’s income.

If an uninsured patient’s and/or responsible party’s (ex. Parents, Spouse, etc.) income is greater than 250% and less than or equal to 400% of the Federal Poverty Guidelines, the patient is eligible for assistance in the form of a reduction in patient liability for all accounts to the amounts generally billed (AGB) as defined below. UPMC Chautauqua WCA patients will also be eligible for this assistance when their respective insurance benefits exhaust.

3. Financial or Medical Hardship: If a patient’s and/or responsible party’s (ex. Parents, Spouse, etc.) income exceeds 250% of the Federal Poverty Level, they may be considered for a Financial or Medical Hardship. UPMC will consider assistance where a patient’s out of pocket expense or patient liability exceeds 15% of family income or where a patient’s medical bills are

© 2020 UPMC All Rights Reserved POLICY HS-RE0722 PAGE 12 of such magnitude that payment threatens the patient’s financial survival. Assistance will be provided in the form of an adjustment of charges to prevent patient liability from exceeding the lesser of 15% of family income or the AGB.

Notwithstanding anything contained in this policy, if an award of financial assistance that does not cover 100% of the charges for the service is granted, the amount due from patients who are eligible under this Policy for discounted care will not be more than amounts generally billed (AGB) as defined below. UPMC in its discretion may waive or modify eligibility requirements after considering all relevant facts and circumstances in order to achieve this Policy’s essential purpose of providing medical care to patients who lack financial means.

VII. AMOUNTS GENERALLY BILLED

UPMC will not charge an eligible individual for emergency or other medically necessary services more than the amount generally billed (AGB) to individuals who have insurance covering such care. UPMC will use the Look-Back method to determine AGB. The AGB is calculated using all claims allowed by the Medicare- Fee–For–Service and Private health insurances (including the Medicaid Managed Payers). For this purpose, UPMC will select the lowest percentage of any hospital facility covered by the policy and apply this percentage to all emergency or other medically necessary care covered by the policy.

For services received at UPMC Chautauqua WCA, AGB will calculated as (lowest percentage of hospital facilities covered by this policy AGB-10%.)

VIII. APPLYING FOR FINANCIAL ASSISTANCE

Eligibility determinations will be made based on UPMC’s policy and an assessment of a patient’s financial need. Uninsured and underinsured patients will be informed of the Financial Assistance Policy and the process for submitting an application. Applicants for financial assistance are required to apply to public programs for available coverage, if eligible, as well as for pursuing public or private health insurance payment options for care provided by UPMC. UPMC will process the request for financial assistance within 30 days of receipt. If there is missing documentation, the patient will be given an additional 30 days to respond to the request.

UPMC will make reasonable efforts to explain the benefits of Medicaid and other available public and private programs to patients and provide information on those programs that may provide coverage for services.

Information on public or private coverage and UPMC’s Financial Assistance Policy will be communicated to patients in easy-to-understand, culturally appropriate language, and in the most prevalent languages spoken in applicable hospital service area communities.

A. Application Process:

Typically, a patient is not eligible for financial assistance until he or she has applied for and is determined to be ineligible for applicable federal and Commonwealth governmental assistance programs. UPMC will make resources available to assist patients in enrolling in and/or applying for federal and Commonwealth government programs. UPMC may decide to process the financial assistance application without the documentation that the patient is ineligible for Medical Assistance or other governmental assistance programs.

All applicants are expected to complete the UPMC Financial Assistance application form (see attachment) and provide requested documents. If documentation is not included with the application, the financial information shared on the application may be used in order to make the financial assistance determination. The patient’s signature will be used as attestation to the validity of the information provided. In addition, while completed applications and supporting documentation are more likely to result in a more efficient application process, financial assistance may be awarded in the absence of a completed application and supporting documentation as provided by this policy under presumptive financial assistance (described below) or otherwise in the discretion of UPMC.

Financial Assistance applications are to be submitted to the following office:

Patient Financial Services Center UPMC Quantum 1 Building 2 Hot Metal Street Pittsburgh, PA 15203 1-800-371-8359 option 2

Requests for financial assistance will be processed promptly and UPMC will notify the patient or applicant in writing within 30 days of receipt of a completed application. If denied eligibility for any of the financial assistance offered, the patient may re- apply at any time. If the patient is denied financial assistance and a payment to satisfy the balance or a payment plan is not established the account may be transferred to a 3rd-party collection agency for follow-up. Please refer to UPMC’s Billing and Collections Policy HS-RE0724.

If the patient is approved for financial assistance, the eligible patient balances will be adjusted accordingly for services up to one year prior to the approval of the application. The application will remain on file for 3-months and may be used to grant financial assistance within the 3-month time period without requesting additional financial information. Cancer patient’s applications will be approved for a 6month forward time period to ensure a continuation of care.

The approval time period for financial assistance eligibility will begin on the date that the patient is determined eligible for assistance and 1-year prior to the date of eligibility. Service dates outside the 1-

If a patient is approved for financial assistance through the application process and has made a payment to the accounts which qualify for financial assistance; payments over $5.00 will be refunded to the extent consistent with the level of financial assistance awarded, with the exception of co- payment.

B. Presumptive Financial Assistance Eligibility:

Presumptive Indigence:

UPMC recognizes that not all patients are able to complete the financial assistance application or provide the required documentation. There may be instances when financial assistance is warranted and the patient qualifies for assistance, despite the lack of formal applications and income assessment described in this policy. In the normal course of assessment of a patient’s ability to pay, UPMC, in its sole discretion, may declare the patient’s account uncollectible and classify the account as meeting eligibility criteria. Presumptive eligibility may be granted to patients based on life circumstances such as:

1. homelessness or receipt of care from a homeless clinic; 2. participation in Women, Infants and Children programs (WIC);

© 2020 UPMC All Rights Reserved POLICY HS-RE0722 PAGE 17 3. receiving SNAP (Supplemental Nutritional Assistance Program) benefits; 4. eligible for other state or local assistance programs, such as Victims of Violent Crimes; 5. deceased patient with no known estate.

When presumptive financial assistance eligibility is established, typically a 100% discount will be available.

Other Presumptive Eligibility:

For patients who are non-responsive to UPMC’s application process, other sources of information, such as estimated income and family size provided by a predictive model or information from a recent Medical Assistance application, may be used to make an individual assessment of financial need. This information will enable UPMC to make an informed decision on the financial need of non-responsive patients utilizing the best estimates available in the absence of information provided directly by the patient.

For the purpose of helping financially needy patients, UPMC may utilize a third-party to review the patient’s information to assess financial need. This review utilizes a healthcare industry-recognized, predictive model that is based on public record databases. The model incorporates public record data to calculate a socio-economic and financial capacity score that includes estimates for income, resources, and liquidity. The model’s rule set is designed to assess

© 2020 UPMC All Rights Reserved POLICY HS-RE0722 PAGE 18 each patient to the same standards and is calibrated against historical financial assistance approvals for UPMC. The predictive model enables UPMC to assess whether a patient is characteristic of other patients who have historically qualified for financial assistance under the traditional application process. Information from the predictive model may be used by UPMC to grant presumptive eligibility in cases where there is an absence of information provided directly by the patient. Where efforts to confirm coverage availability have been unsuccessful, the predictive model provides a systematic method to grant presumptive eligibility to financially needy patients.

In the event a patient does not qualify for the highest level of financial assistance under the presumptive rule set, the patient may still provide the requisite information and be considered under the traditional financial assistance application process. When a patient is denied financial assistance though the presumptive eligibility process, a letter will be sent to the patient along with a financial assistance application. The patient will have 30 days to complete the application prior to sending the account to a 3rd- party collection agency.

Presumptive screening provides benefit to the community by enabling UPMC to systematically identify financially needy patients, reduce administrative burdens, and provide financial assistance to patients who have not been responsive to the financial assistance application process.

UPMC’s Financial Assistance Policy (FAP), the FAP application form and the plain language summary of the FAP (the “FAP Documents”) shall be available to all UPMC patients as follows:

A. The FAP, FAP application form and a plain language summary of the FAP are available on UPMC’s website, (https://www.upmc.com/patients-visitors/paying- bill/services/apply), searchable by the mechanism applicable to the site generally. The FAP Documents will be printable from the website.

B. The FAP, the FAP application form and plain language summary of the FAP are available upon request and without charge, both in public locations in UPMC hospitals and by mail.

C. Visitors to the facility are informed and notified about the FAP and availability of the FAP Documents by notices in patient bills and by posted notices in emergency rooms, urgent care centers, admitting and registration departments, hospital business offices, and patient financial services offices that are located on facility campuses and at other public places as UPMC may select. Information will also be included on public websites. Referral of patients for financial assistance may be made by any member of the UPMC staff or medical staff, including physicians,

X. APPEALS AND DISPUTE RESOLUTION

Patients may seek a review from UPMC in the event of a dispute over the application of this financial assistance policy. Patients denied financial assistance may also appeal their eligibility determination.

Disputes and appeals may be filed by contacting the Director of UPMC Revenue Cycle, Patient Advocacy. The basis for the dispute or appeal should be in writing and submitted within 30 days of the patient’s experience giving rise to the dispute or notification of the decision on financial assistance eligibility.

Disputes or appeals should be submitted to the following office:

Director, UPMC Revenue Cycle, Patient Advocacy Quantum 1 Building 2 Hot Metal Street Pittsburgh, PA 15203

XI. COLLECTIONS IN THE EVENT OF NON- PAYMENT

UPMC will not engage in Extraordinary Collection Actions, as defined by applicable federal laws. If the individual is already a Financial Assistance recipient and he/she is cooperating in good faith to pay his/her balance but nonetheless experiencing difficulty, UPMC will endeavor to offer an extended payment plan.

Refer to UPMC Billing and Collections Policy HS- RE0724 for the actions the hospital facility may take in the event of nonpayment. This policy may be obtained at no cost by contacting the Patient Financial Services Center at 1-800-371- 8359.

XII. REGULATORY REQUIREMENTS

In implementing this Policy, UPMC management and facilities shall comply with all applicable federal, state, and local laws, rules, and regulations.

XIII. RECORD KEEPING

UPMC will document all financial assistance in order to maintain proper controls and meet all internal and external compliance requirements.

XIV. POLICIES REFERENCED WITHIN THIS POLICY HS-RE0724 Patient Billing and Collections

SIGNED: Jeffrey Porter Vice President, Revenue Cycle ORIGINAL: October 1, 1999 APPROVALS: Policy Review Subcommittee: June 12, 2020 (effective July 1, 2020) Executive Staff: PRECEDE: June 28, 2019 (effective July 1, 2019) Formatted: Font: (Default) Tahoma, 18 pt SPONSOR: Associate Director, Revenue Cycle

* With respect to UPMC business units described in the Scope section, this policy is intended to replace individual business unit policies covering the same subject matter. In-Scope business unit policies covering the same subject matter should be pulled from all manuals.

UPMC Presbyterian Shadyside, Oakland campus

UPMC Presbyterian Shadyside, Shadyside campus

Western Psychiatric Institute and Clinic

Children's Hospital of Pittsburgh of UPMC

Magee-Women's Hospital of UPMC

UPMC St. Margaret

UPMC Passavant, McCandless campus

UPMC Passavant, Cranberry campus

UPMC McKeesport

UPMC Mercy

UPMC Bedford

UPMC East

UPMC Hamot

UPMC Northwest

UPMC Altoona

UPMC Horizon, Shenango campus

UPMC Horizon, Farrell campus

UPMC Jameson

UPMC Kane

UPMC Williamsport Hospital

UPMC Muncy Hospital

UPMC Lock Haven Hospital

UPMC Wellsboro Hospital

UPMC Chautauqua WCA

UPMC Somerset

PROVIDER LIST

Butler Cancer Associates, Inc.

Center for Emergency Medicine of Western Pennsylvania, Inc.

Donahue & Allen Cardiology-UPMC, Inc.

Erie Physicians Network-UPMC, Inc.

Fayette Oncology Associates

Fayette Physician Network, Inc.

Hematology Oncology Association

Heritage Valley/UPMC Multispecialty Group, Inc.

Jefferson/UPMC Cancer Associates

Lexington Anesthesia Associates, Inc.

Oncology-Hematology Association, Inc.

Passavant Professional Associates, Inc.

Regional Health Services, Inc.

Renaissance Family Practice-UPMC, Inc.

Tri-State Neurosurgical Associates- UPMC, Inc.

University of Pittsburgh Cancer Institute Cancer Services

University of Pittsburgh Physicians, Inc.

UPMC Altoona Partnership for a Health Community

UPMC Altoona Regional Health Services, Inc.

UPMC Community Medicine , Inc.

UPMC Complete Care, Inc.

UPMC Emergency Medicine, Inc.

UPMC Multispecialty Group, Inc.

UPMC/HVHS Cancer Center

UPMC/Jameson Cancer Center

UPMC/St. Clair Hospital Cancer Center

UPMC/Conemaugh Cancer Center

Susquehanna Physician Services d/b/a Susquehanna Health Medical Group- SHMG

Tioga Healthcare Providers-THCP

Somerset Palliative Care Associates

Somerset Facility Based EKG Interpretation Services

Somerset Anesthesia, Inc. Foundation Radiology

UPMC Somerset Ear, Nose and Throat

UPMC Somerset Behavioral Health

Somerset Health Services, Inc.  Somerset Cardiology  Somerset Family Practice  Somerset Orthopedics  Somerset Pain Management  Somerset Pulmonary Medicine  Somerset Surgical Services  Somerset Women’s Health Center  Somerset Urology

UPMC CHAUTAUQUA WCA PROVIDER LIST

NAME MI SPECIALTY Internal Blasius , Jonathan Medicine & M.D. Pediatrics

Bommireddipalli, Internal Srinvas MD Medicine

Buonaiuto, Pediatrics Salvatore MD Critical Care

Colosimo, Christopher DO J Hospitalists

Family McKimm, Scott DO R Medicine

Internal Menon ,Zubin Medicine

Internal Movva, Ashok MD B Medicine

Movva, Khusboo Internal MD Medicine

Murphy, Timothy Emergency DO G Medicine

Ramlal, Vanessa Family MD G Medicine Internal S Medicine

Sarwar, Internal Muhammad MD A Medicine

Swagler, William DO A

Toturgul, David MD

Ferdman, Barbara MD R Pediatrics

General Grijalva, Galo MD Surgery

Andrews, Thomas MD Gynecology

Shrestha, Pujan Laborist/ MD OB/GYN Laborist/ Walsh, Andrea MD Hendrika OB/GYN

Johnson-Clopp, Jill NP OB/GYN

Brar, Mandeep MD K OB/GYN Wiebenga, Jeanne MD OB/GYN

Dolensek, Christian MD OB/GYN

Persaud, Andre OB/GYN

Minger, Jill OB/GYN

Glenn, James MD Michael Orthopedics

Kavjian, David MD Orthopedics

Physical Medicine & Kelly, Brooke DO K Rehab

Caruso, Chelsea PA Orthopedics

Elton Garvin Radiology Laguerre, Max MD S Oncology

Vu, Khanh Thi-Nha Radiology MD Oncology

Abbasi, Israr MD PSYCHIATRY

Bailey ,Kristine NP PSYCHIATRY

Chaudhry , Monir A. MD PSYCHIATRY

Meer , Shahnawaz MD PSYCHIATRY

Munella, Allison PA PA

Sazonov, Adelia DO A PSYCHIATRY

Scott , Craig LCSW LCSW

Verdonik, Frederick PHD

Verleni ,Gust PA

Warriner , Walter NPP

Whitver, Stewart NP

Mitchell, Michael MD Sports Med

Mihalko ,Kerry RD Registered CDE Dietician

Certified Holthouse , Dietician- Bethann CD Nutritionist

Zatyko , Caroline Registered RD CDE Dietician

Tuccio , Anthony T DPM Podiatry

Tuccio , Mark J DPM Podiatry

Dubyne, Lauren Audiology

Bedient , Laurie Audiology Audiology

Miller, Brianna Audiology Audiology/ Lorenc, Cynthia Speech

© 2020 UPMC All Rights Reserved POLICY HS-RE0722 PAGE 38 Non-Covered Providers *This list will be updated quarterly UPMC Altoona Natalie M Aikens PA-C Rajih A Alkhafaji MD Bert Joseph Altmanshofer DPM Gohar Ashraf MD Sathya Narayana Aswathappa MD Robert Michael Baffic Path A Robert Joseph Bailey DO Loni M Baird PA-C Taylor Ann Baronner PA-C Bradley Alan Barter DO Liang Ruey Bartkowiak MD Paul R Barton DPM Robert Todd Bechtel MD Brett Joshua Beech PA-C Daniel Titus Bender PA-C Cara Kathleen Bennett PA-C Ashley Suzanne Benton PA-C Donald Joseph Betar Jr DMD, FAGD Gretchen A Black CST Sandralee Ann Blosser MD Edmond J Bouassaf MD Jessica B Brode CST

© 2020 UPMC All Rights Reserved POLICY HS-RE0722 PAGE 39 Heather Nicole Bryant PA-C Ronald Joseph Brzana MD Robert Michael Budd MD Adam Marek Budny DPM Brittany Lauren Burke PA-C Daniel Wardlaw Burke MD James Paul Burke MD, PhD Ricardo C Calla PA-C Mark Christopher Campbell MD Ufuk Fusun Cardakli MD Ralph A Cardamone MD Brian Wintrode Carlin MD William Arthur Castaldo MD Jill Marie Cavalet PA-C Rakesh Kedar Chopra MD Debby Chuang MD David Scott Claar PA-C Marc Joseph Clapper DO Michael Jonathan Clark MD Vanessa Renee Colquhoun PA-C Bridget Olivia Corey DPM Cecilia Mendoza Cortes-Rogers MD Roland Crevecoeur MD Anthony Camillo Damin PA-C NiiDaako Pious Darko DO Michael John Davies MD

© 2020 UPMC All Rights Reserved POLICY HS-RE0722 PAGE 40 Donna D Davis CRNP Lance C DeFrancisco MD Levi Nicholas DeLozier MD Lori A Demko CRNP John Michael Dinger MD Johnathan Richard Dodson CRNP Mohammad Aboo Dowlut MD Michael James Drass MD Michelle Lee Dunio CRNP David Clayton Faber MD Katherine Ford CRNP Anthony Joseph Froncillo DO Gregory John Fulchiero MD, MS Ricardo Garcia-Rivera MD Zane H Gates MD James Anthony Gerardo MD, PhD Erin Elizabeth Gilroy PA-C Adam Clayton Goddard DDS David Adair Green MD Anju Gupta MD Pawan Kumar Gupta MD, FACP Andrew William Gurman MD Nadine M Gwizdak CST Sean P Hampton DO Mary Catherine Haney PA-C Nathan Harker NP

© 2020 UPMC All Rights Reserved POLICY HS-RE0722 PAGE 41 Elizabeth A Heverly PA-C Johnson Grant Hormell MD Patricia Mary Hoyne MD John W Hoyt MD George Hromnak MD Joseph Huang MD Daniel Johnson CRNP Renee Lynne Jones MD Alice Plummer Joyce MD John Patrick Joyce MD Melissa Marie Kagarise PA-C Alan Joseph Kanouff DO Kusum Rajgopal Kansal MD Yi How Kao MD David Lee Kerstetter Jr MD Mansoora S Khalid Path A Mushtaq Hussain Khalid MD Fred K Khalouf DO Nicholas Craig Kinback MD Alan Jan Kivitz MD Jeremy A Klapper MD Frank Kosnosky Jr CRNP Mandi Lyn Krach CRNP Regina Suzanne Kuncelman CRNP Barbara Maurice Labban MD Andrea Lynne Lacki PA-C

© 2020 UPMC All Rights Reserved POLICY HS-RE0722 PAGE 42 Melissa Marie Lafferty PA-C Dawn Landeck CRNP Elizabeth Lantznester CRNP Lori Ann Lavelle DO Susan M LeComte RN David Richard Lee MD Christina Lenk MD Alexis Nicole Prebihilo Ley DPM Christopher James Lincoski MD Chelsea Nicole Link PA-C Darron Blaine Locke MD Megan M Long PA-C Fanny Xhajanka Louton MD, MPH Robert Brian Louton MD Kornel Lukacs MD Jorden M Luther PA-C Maryann Lyons PA-C Ronald P Mack PA-C Jill Lynn Madden PA-C Mark Dane Maney PA-C Marcos A Manon MD Matthew Benjamin Maserati MD Bonita Ann Mazzei RN, BSN Chris Stephen McClellan DO Lisa Long McElheny RN Jason E McGowan MD

© 2020 UPMC All Rights Reserved POLICY HS-RE0722 PAGE 43 Nickie L McIntire CRNP Ralph David McKibbin MD Hailee Merrill PA-C Dena Sicola Miles PA-C Russell Paul Miller MD Rafael Angel Morales MD Vincent Francis Morgan MD Lenore Jolene Moyer DPM Donald E Mrdjenovich DPM Frederick Timothy Murphy DO Heidi Ann Murphy PA-C Barbara J Naimoli DO Muhammad Ghassan Naji MD Autumn Nesbitt CRNP Nikita Igorevich Neverov MD Hugh D Newman III DO Saleena Ruth Niehaus DPM Daniel Thomas Novak Jr DMD Ciceron L Opida MD William J Paronish MD Susan Jane Parr AUD Mitul Takshak Patel MD Rakesh R Patel DO Hector Luis Peniston-Feliciano MD Kylie D Plummer PA-C Joshua Port MD

© 2020 UPMC All Rights Reserved POLICY HS-RE0722 PAGE 44 Gregory M Price MS Laurence Alan Primack MD Angel Quiano Raposas MD Gary A Raymond DPM Sarah D Reed PA-C Kaliah Reeves CRNP John Francis Reinhardt DO Sarah Marie Reinhardt DO James E Repko DPM Elias Mounif Rifkah MD Jay Allen Robinson MD Gina Lee Roland PA-C Jeffrey Marvin Rosch MD Angela Wai-Chung Rowe DO Matthew Thomas Sabol DPM Anan H Said MD Shawn Craig Saylor DO Victoria J Scott CRNP Robert J Singer DO Duminda S Siripala MD Kumbalatara A Siripala MD Laurie S Smith CRNP Mandy Kay Smith PA-C Todd Allen Sponsler MD Kimberly A Springer CST Todd Michael Stasik PA-C

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UPMC Bedford

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UPMC Chautauqua Vijaya Kumar Agarwala MD Michel E Akl MD Mohammed Aladdin MD Maria Eliza Alexianu MD, PhD Evan David Allen MD Nancy A Allen MD Laith Rafi Altaweel MD Eric Robert Anderson MD Debra Lynn Arndt CNM Eric D Arnone MD Sara Banerjee MD Andrew Jeffrey Barbash MD Tamara Thair Barghouthi MD Peggy P Bastien MD Ajay Behari MD Kirsten A Bishop PA-C Shrikant C Bodani MD Brian J Bohner MD Alan D Bolnick MD Jay M Bolnick MD Raymond Bozman MD Timothy Paul Braatz MD Mary E Brooks CRNA Casey Thomas Cheney Brown CRNP

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UPMC Children’s Hospital of Pittsburgh Meena Adhar MD Julia Dawson Allan PA-C

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UPMC Hamot Sarah Elizabeth Achenbach MD Gregory Hugh Adkisson MD Sartaj Sultana Ahmed MD John David Albert II MD David Ricardo Pereira Almeida MD John Lawrence Alonge DDS Jack Bryant Anon MD Luis F Aparicio MD Autumn Nicole Arkwright CRNA Timothy Joseph Armanini DDS Douglas B Babel MD Robert Michael Badgett CRNA Muhammad Ahsan Baig MD Hallie N Baldwin DA Robert Christopher Baldwin MD John David Basile DMD Alexander C Batchev DO Robert V Beckman CRNA Kim Jean Bennett CNM Eric Wright Bernstein MD Zahida Bhatti MD

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UPMC Horizon Bruce Edward Abbott DPM Michael E Abdul-Malak MD Alysandra Andrusky PA-C Anup Singh Bains MD Michael Craig Beaudis DPM Jeffrey Allan Bedlion MD

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UPMC Jameson

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UPMC Lock Haven Mona Najib Arabi MD Derek Raphael Armfield MD Kris Karl Armson MD Joseph M Bender MD Praful U Bhatt MD Veeral Ravindra Bhoot DO Todd Michael Blodgett MD Alison A Botek MD Michael Francis Boyle MD Kathryn McGannon Brookover CRNA Robert S Cacioppo CRNA Stefano Carpenetti DO Tong Saa Chai MD Pravin G Chapla MD Sang Youl Choi MD James M Ertel MD Renee R Francisco CRNA Gretchen S Gaus CRNA

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UPMC Magee – Women’s Hospital Sandeep Anand MD Chelsea Renee Anderson CRNP Gregory Charles Anderson MD Joseph F Aracri DO Femabelle Bautista DO Jenna Rae Bench CRNP Jennifer Frances Blassey PA-C Natalie Marie Brown PA-C Alexus Ann Bushee PA-C Matthew Stephen Caldwell CRNA Anne Chen MD Wayne C Chen DO Pamela J Clair MD William Fiore Coppula MD Michael Joseph Daly MD Anthony Michael DiGioia MD Divna Djokic MD

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UPMC McKeesport Mumtaz Ahmad Alvi MD Elmer Lacuata Apaga MD Donald W Beck DPM Daphne Patricia Bicket MD Phillip W Brown DPM Diane M Buchbarker MD James Thomas Campagna MD Maricel Del Carmen Castaner MD Mehboob Khurram Chaudhry MD Rahat Mahmood Chaudhry MD Lisa M Cibik MD Louis August DiToppa DO Jessica L Erb DNP, CRNP Thomas Francis Findlan DO Coreyann Fluker CRNP Eric Albert Freiwald DPM Rocco Anton Fulciniti MD Joseph Paul Gioffre DPM Michael Alan Gottlieb MD

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UPMC Mercy Omar Farooq Abbasi MD Rocco Joseph Adams MD Ravikumar Alagar MD Mitchell Edward Antin DO Ragunath Appasamy MD, PhD Christopher Michael Ban DMD Stacy M Bangert PA-C Nicholaus Edward Barbosa DMD, MD Alicia Baum MD Randall Lee Beatty MD

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UPMC Passavant Debra Tanner Abell MD Syed Tahir Ali MD David Bradley Amos MD Mark D Athanas PA-C Kate Elizabeth Bachner CRNP Herman Singh Bagga MD Sarrah Germaine Bair CRNP Virginia Marian Balderston MD Marshall Louis Balk MD Christ Anthony Balouris MD John A Bamonte DMD Michael Kim Ban DMD

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UPMC Presbyterian Edward Charles Adlesic DMD Sam Sarmad Bakuri DMD Richard Earl Bauer III DMD, MD Barbara Lynn Baumann PhD Elizabeth Bilodeau DMD, MD Stanley Desire Bosta DPM Meghan Alexa Brunnet PA-C Susan Elizabeth Calderbank DMD William M Castillo MD John Joseph Charletta DMD William Lee Chung DDS, MD Kathy Claypoole CRNA Gilles Clermont MD Bernard James Costello DMD, MD Thomas James D'Orazio MD, PhD Pradeep Dhakarwal MD Roshan Dhawale MD, MPH

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UPMC ShadySide Amesh Ashok Adalja MD Marc Jeffrey Adelsheimer MD

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UPMC Williamsport Jamie L Adam MD, PhD Carol Joy Adams CRNA Anjali Agrawal MD Manohar Aribandi MD Gregory V Babigian MD Keith Alan Baker MD James S Baldys MD Katelyn Baldys CRNP Christine M Barbour Kavanagh CRNP William P Bartlow MD John C Becker DO Michael I Belenko MD

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